UTAH PLAN GUIDE. Your Destination for Small Business Solutions SM. Plans effective August 1, UT (4/09)

Transcription

1 UTAH PLAN GUIDE Your Destination for Small Business Solutions SM Plans effective August 1, UT (4/09)

2 U ta h p l a n G U I D E Health care is a journey A e t n a Av e n u e i s t h e way I n t h i s g u i d e : 2 Small business commitment 3 Benefits for every stage of life 4 Medical overview 5 Managing health care expenses 7 Medical plan options 14 Dental overview 15 Dental plan options 20 Life & disability overview 22 Life plan options 22 Disability plan options 23 Life & disability plan options 24 Underwriting guidelines 38 Product specifications 42 Limitations and exclusions 44 Group enrollment checklist As a small business owner, providing value to your customers and growing your business are your top priorities. Yet, today health care is a business issue for every entrepreneur. Small businesses need insurance benefits plans that fit their workplace. Aetna Avenue provides employers with a choice of insurance benefits solutions. We know that choice, ease and reputation are as valuable to employers as they are to employees. Aetna offers a variety of plans for small business from medical plans, to dental, life and disability plans. Health/dental insurance plans, life and disability insurance plans/policies are underwritten by Aetna Life Insurance Company (Aetna).

3 C H O I C E For business owners and employees At Aetna, we provide employers a choice of insurance benefits plans. Within these benefits programs, employers can choose specific plan designs that fit business and employee needs. Employees have access to a wide network of doctors and other providers ensuring that they have a choice in how they receive their health care. Medical plans supporting members on their health care journey ß Consumer-directed health plans (CDHP) ß Value PPO plans ß Traditional plans Dental, life and disability plans providing valuable protection ß PPO ß PPO Max ß Preventive ß Basic term life insurance ß Disability plans ß Packaged life and disability plans E a s e Allowing you to focus on your business Employers want to focus on their customers and growing their business not the insurance benefits program. Aetna makes sure that our plan designs are easy to set-up, administer, use and provide support to ensure your success. Administration making it work for your business Aetna s plan designs automatically process health claim reimbursements, provide a password-protected website to keep track of accounts and are supported by knowledgeable service representatives. Our representatives are available to answer your questions and work with you when you need them. Ready on day-one making it work for your employees Once employees are members of the Aetna health benefits and health insurance plans, they ll have access to our various tools and resources to help them use the plans effectively from the start. Aetna Navigator our online resource for employers, members and providers ß DocFind to locate doctors in the neighborhood ß Track medical claims online ß Discount programs for eye, dental and other health care ß Personal Health Record providing a complete picture of health ß Temporary ID cards available for members to print as needed Knowledgeable customer service a valuable resource for members ß Ready to answer questions ß Online access 24 hours a day, 7 days a week ß access for answers to your questions Aetna Health Connections SM disease management Our newly redesigned capabilities offer support for over 30 conditions as well as integrated care for members with multiple conditions. The program includes cutting-edge technology that helps improve patient safety, doctor communication and more. R e p u tat i o n In business it s everything Your reputation is important to your business. At Aetna, our reputation is just as important. With 150 years of experience, we value our name, products and services and focus on delivering the right solution for your small business our reputation depends upon it. Our account executives, underwriters and customer service representatives are committed to providing your small business the valuable service it deserves. We want you to know that Aetna delivers. M E D I C A L / P H A R M A C Y D E N TA L L I F E / D I S A B I L I T Y U N D E R W R I T I N G

4 U ta h p l a n G U I D E A e t n a Av e n u e s c o m m i t m e n t t o s m a l l b u s i n e s s e m p l o y e r s We know that small business owners insurance benefits needs are often different than a larger employer. Aetna Avenue focuses on employers with 2 50 employees and our insurance benefits programs are designed to work for this size group. We ll work with you to determine the right plans for your business and assist you through implementation. A e t n a s m a r k e t m a p Guiding your small business health care journey Aetna s market map is a resource for brokers and employers to help determine the right insurance benefits plan for their business. The market map asks specific questions related to the business and employee need in order to narrow the field of plan design choices. Basic benefits for your employees Limiting the expense to your business Allowing employees to buy-up and share more of the cost You might be a Basic buyer These plans fit Value plans PPO Basic $1,500 PPO Limited 50/50 PPO $750 Value PPO $1,000 Value PPO $1,500 Value PPO $10, % Employee responsibility These plans fit D o y o u va l u e Consumerism s ability to make a difference Tools and resources to support consumerism Innovative plan design You might be a Value seeker Consumer-directed health plans PPO $2, % HSA Compatible PPO $2,500 80% HSA Compatible PPO $3,500 80/60 HSA Compatible $2,500 Coinsurance Traditional benefits plans Limiting the financial impact on employees You might be a Traditionalist These plans fit Traditional plans PPO $250 80/60 PPO $500 80/60 PPO $750 80/60 PPO $1,000 80/60 2

5 Y o u n g S i n g l e s Consumer-directed health plans Value Plans Y o u n g Fa m i l i e s Traditional plans E s ta b l i s h e d Fa m i l i e s Consumer-directed health plans Value Plans E m p t y N e s t e r s Consumer-directed health plans H e a lt h i n s u r a n c e b e n e f i t s f o r e v e ry s ta g e o f l i f e Y o u n g s i n g l e s Includes singles and couples without children Ready to conquer the world? Thinking big thoughts? Well, one of those thoughts should be about health coverage. Since they re probably on a budget, they might want an affordable policy with lower monthly payments and modest out-ofpocket costs that also provides for quality preventive care, prescription drug coverage and financial protection to help safeguard their assets. Y o u n g fa m i l i e s Includes married couples and single parents with young children and teens Children tend to get sick more than adults which means employees and their pediatricians get to know each other quite well. It also means they re probably looking for health coverage with lower fees for office visits, lower monthly payments and caps on their out-of-pocket expenses. And, of course, they can benefit from quality preventive care for the entire family. Established families Includes married couples and single parents with teens and college-aged children As the children get older, the entire family s needs change. Time management is important for active parents and children. Teenagers still need checkups and care for injuries and illness, while parents need to start thinking about their own needs, like plan designs that cover preventive care and screenings and promote a healthy lifestyle. And college brings financial concerns to the forefront, as well as the need for a national network. E m p t y n e s t e r s Includes men and women age 55 and over with no children at home The kids are leaving home. It s a wistful time, but also an exciting one. What are the plans? Travel? Leisure? Reassessing health coverage needs? These employees are probably looking for a policy that combines financial security with quality coverage for prescriptions, hospital inpatient/outpatient services and emergency care. M E D I C A L / P H A R M A C Y D E N TA L L I F E / D I S A B I L I T Y U N D E R W R I T I N G 3

6 Aetna s Utah network has more than 5,200 health care providers and 38 hospitals from both the Intermountain and MountainStar health care systems.* U ta h p l a n G U I D E Aetna Avenue M e d i c a l O v e r v i e w A e t n a P P O p l a n p r o v i d e r n e t w o r k * Utah counties Beaver Box Elder Cache Carbon Daggett Davis Duchesne Emery Garfield Grand Iron Juab Kane Millard Morgan Piute Rich Salt Lake San Juan Sanpete Sevier Summit Tooele Uintah Utah Wasatch Washington Wayne Weber W h at i s P i c k - A - P l a n 3? Pick-A-Plan 3 is Aetna Small Group s suite of plans designed specifically with small businesses in mind. These plans provide choice, flexibility and simplicity. Pick-A-Plan 3 offers the following advantages: Greater employee choice Employers with 5 or more enrolling employees can offer any 3 of the 18 available plan designs. Flexibility and affordability Employers with 5 or more enrolling employees can create a customized benefits package from any of our plan types and plan designs. Aetna offers a variety of plans at different price points. Employers may designate a level of contribution that meets their budget. Total freedom Aetna offers 18 plan choices that range in price and benefits to help meet each individual employee s needs, whether they are lower premiums or lower out-of-pocket costs at the time services are received. Easy administration Setting up this program is simple: 1. The employer can choose up to 3 plans from the Employer Application 2. The employer chooses how much to contribute 3. Each employee chooses the plan that s right for him or her A e t n a P P O p l a n The Aetna PPO insurance plan offers members the freedom to go directly to any recognized provider for covered expenses, including specialists. No referrals are required. ß Emergency care coverage anywhere, anytime, 24 hours a day ß Large provider network ß No claim forms in network ß If members choose a provider from Aetna s network of participating physicians and hospitals, out-of-pocket costs will be lower ß If members choose a physician or hospital outside of the network, out-of-pocket costs will be higher, except for emergency treatment ß Deductibles and coinsurance apply Pick-A-Plan 3 *Network subject to change. Target audience Plan choices Every small business with 5+ enrolled employees Up to 3 of the 18 available plans Minimum participation 2 4 enrolled employees Single or dual option available 5 or more enrolled employees Triple option available Employer contribution 50% of the employee rate or $120 defined contribution or the actual cost of the plans picked, whichever is less. Rating options 5 50 employees tabular 4

7 C o n s u m e r - d i r e c t e d h e a lt h p l a n s ( C D H P ) Consumer-directed health insurance plans are benefit programs that combine a high-deductible health plan (HDHP) with a Health Savings Account to offer financial protection while shifting accountability to use lower-cost services. When paired with a HSA, they provide employers and their qualified employees with an affordable tax-advantaged solution that allows them to better manage their qualified medical and dental expenses. What makes Aetna s Small Group highdeductible health plans (HDHP) unique? All of our HDHPs include an embedded deductible which means lower out-of-pocket costs! What is an embedded deductible? With an Aetna HDHP each covered family member only needs to satisfy his or her individual deductible before plan coinsurance applies. Most HDHPs in today s marketplace require satisfaction of the entire family deductible first. A way t o m a n a g e h e a lt h a n d h e a lt h c a r e e x p e n s e s Health Savings Account (HSA) The Aetna HealthFund HSA, when coupled with a HSA-compatible high-deductible health benefits and health insurance plan, is a tax-advantaged savings account. Once enrolled, account contributions can be made by the employee and/or employer. The HSA can be used to pay for qualified expenses tax free. ß You own your HSA ß Contribute tax free H S A A c c o u n t ß You choose how and when to use your dollars ß Roll it over each year and let it grow ß Earns interest, tax free T o d ay Use for qualified expenses with tax-free dollars Y o u r H S A P l a n F u t u r e Plan for future and retiree health-related costs H i g h - d e d u c t i b l e h e a lt h p l a n ß Eligible in-network preventive care services may not be subject to the deductible; however, a copay or coinsurance may be charged ß You pay 100% until deductible is met, then only pay a share of the cost ß Meet out-of-pocket maximum, then plan pays 100% M E D I C A L / P H A R M A C Y D E N TA L L I F E / D I S A B I L I T Y U N D E R W R I T I N G 5

8 Annual HSA contributions for 2009 are $3,000 per individual/$5,950 per family. Maximums will be adjusted for the cost of living in future years. For more information, refer to U ta h p l a n G U I D E A d m i n i s t ra t i v e f e e s FEE DESCRIPTION HSA FEE Initial Set-Up $0 Monthly Fees $0 POP* Initial Set-Up** $150 Renewal $75 HRA and FSA*** Initial Set-Up* 2 25 Employees $ Employees $450 Renewal Fee Monthly Fees Additional Set-Up Fee for stacked plans (those electing an Aetna HRA and FSA simultaneously) Participation Fee for stacked participants Minimum Fees 50% of the initial set-up fee $5.00 per participant $150 $9.75 per participant 0 25 Employees $10 per month minimum Employees $5- per month minimum TRA Annual Fee $350 Transit Monthly Fees Parking Monthly Fees COBRA Annual Fee Employees Monthly Fee $4.25 per participant $3.15 per participant $50 $0.85 per employee Health Reimbursement Arrangement (HRA) The Aetna HealthFund HRA combines the protection of a deductible-based health plan with a health fund that pays for eligible health care services. The member cannot contribute to the HRA, and employers have control over HRA plan designs and fund rollover. The fund is available to an employee for qualified expenses on the plan s effective date. The HRA and the HSA provide members with financial support for higher outof-pocket health care expenses. Aetna s consumer-directed health products and services give members the information and resources they need to help make informed health care decisions for themselves and their families while helping lower employers costs. Section 125 Cafeteria Plans and Section 132 Transit Reimbursement Accounts Employees can reduce their taxable income, and employers can pay less in payroll taxes. There are three ways to save: Premium Only Plans (POP) Employees can pay for their portion of the group health insurance expenses on a pretax basis. First-year POP fees waived with the purchase of medical with 5-plus enrolled employees. Flexible Savings Account (FSA) FSAs give employees a chance to save for health expenses with pretax money. Health Care Spending Accounts allow employees to set aside pretax dollars to pay for outof-pocket expenses as defined by the IRS. Dependent Care Spending Accounts allow participants to use pretax dollars to pay child or elder care expenses. Transit Reimbursement Account (TRA) TRAs allow participants to use pretax dollars to pay transportation and parking expenses for the purpose of commuting to and from work. COBRA administration Aetna COBRA administration offers a full range of notification, documentation and record-keeping processes that can assist employers with managing the complex billing and notification processes that are required for COBRA compliance, while also helping to save them time and money. *First year POP fees waived with the purchase of medical with 5-plus enrolled employees. ** Non-discrimination testing provided annually after open enrollment for POP and FSA only. Additional off-cycle testing available at employer request for $75 fee. Non-discrimination testing only available for FSA and POP products. *** Aetna FSA pricing is inclusive for POP. Debit cards are available for FSA only. Contact Aetna for further information. For HRA, if the employer opts out of Streamline, the fee is increased $1.50 per participant. Aetna HealthFund HRAs are subject to employer-defined use and forfeiture rules. Health information programs provide general health information and are not a substitute for diagnosis or treatment by a physician or other health care professional. Information subject to change. Aetna reserves the right to change any of the above fees and to impose additional fees upon prior written notice. 6

9 A e t n a S m a l l G r o u p P P O P l a n s NEW PLAN NAME Utah PPO $250 80/60 Utah PPO $500 80/60 Utah PPO $750 Value OON Reimbursement Recognized amount* Recognized amount* Network Open Choice PPO N/A Open Choice PPO N/A Open Choice PPO N/A Recognized amount* Member Benefits Network Out-of-Network Network Out-of-Network Network Out-of-Network Member Coinsurance (Applies to most services) Calendar Year Deductible** (In-Network and Out-of-Network accumulate separately) Calendar Year Coinsurance Limit*** (does not include deductible) 20% 20% 20% $250 per member $1,500 per member $500 per member $3,000 per member $500 per member $2,000 per member $1,000 per member $4,000 per member $750 per member (three-member $2,500 per member (three-member Lifetime Maximum Benefit $2,000,000 $2,000,000 $2,000,000 Primary Physician Office Visit Specialist Office Visit $10 copay $20 copay $15 copay $25 copay $20 copay $40 copay $1,500 per member (three-member $5,000 per member (three-member Chiropractic Services Covered under PT/OT/ST Covered under PT/OT/ST Covered under PT/OT/ST Outpatient Lab and X-ray (services included with office visit cost sharing) Outpatient Complex Imaging (CAT, MRI, MRA/MRS and PET Scans) Outpatient Physical, Occupational, Speech and Chiropractic Therapy PT/OT/ST/CT Limits Physical Exams Adults (Age and frequency schedules apply; $300 max benefit per exam) Well-Child Exams (Age and frequency schedules apply) Routine GYN (Frequency schedules apply) $0 $0 $20 30% 50% 30% 50% 30% 50% 20% 20% 20% 30 visits per cal year all therapies combined, Network and Out-of-Network combined $10 copay $10 copay $20 copay $15 copay $15 copay $25 copay 30 visits per cal year all therapies combined, Network and Out-of-Network combined $20 copay $20 copay $40 copay 30 visits per cal year all therapies combined, Network and Out-of-Network combined Inpatient Hospital 20% 20% 20% Outpatient Surgery OP Hospital Department Freestanding Facility Emergency Room (Copay waived if admitted.) Urgent Care Prescription Drugs Retail: per 30-day supply Mail Order: 2.5 times retail copay, 90-day supply available Self-Injectable Drugs (retail and mail order) 20% 20% 20% after $100 copay $50 copay Paid as in-network 20% 20% 20% after $150 copay $50 copay Paid as in-network $200 copay + 20% 20% 20% after $150 copay $75 copay $10/$30/$50 $10/$30/$ % $10/$30/$50 $10/$30/$ % $15/$40/$60 3X Retail for 90 day supply via MOD 20% 20% 20% 20% 20% 20% $200 copay + Paid as in-network $15/$40/$ % * Payment for Non-Preferred facility care is determined based upon Aetna s Allowable Fee Schedule. Payment for other Non-Preferred care is determined based upon the negotiated charge that would apply if such services or supplies were received from a Preferred Provider. For more information, see the How Aetna pays claims for out-of-network benefits brochure. This brochure will be mailed directly to members after they enroll. ** Unless otherwise indicated, the Deductible must be met prior to benefits being payable. Once 2 individual members of a family each satisfy their Deductible amount separately, all family members will be considered as having met their Deductible for the remainder of the calendar year. For the Value plans, once 3 individual members of a family each satisfy their Deductible amount separately, all family members will be considered as having met their Deductible for the remainder of the calendar year. *** All covered expenses accumulate separately toward the preferred and non-preferred Coinsurance Limit. Only those preferred & non-preferred expenses resulting from the application of coinsurance percentage (except any penalty amounts) may be used to satisfy the Coinsurance Limit. Certain member cost sharing elements including deductible, copays, pharmacy, mental health and substance abuse do not apply toward the Coinsurance Limit. Once 2 individual members of a family each satisfy their Coinsurance Limit separately, all family members will be considered as having met their Coinsurance Limit for the remainder of the calendar year. For the Value plans, once 3 individual members of a family each satisfy their Coinsurance Limit separately, all family members will be considered as having met their Coinsurance Limit for the remainder of the calendar year. M E D I C A L / P H A R M A C Y D E N TA L L I F E / D I S A B I L I T Y U N D E R W R I T I N G 7

10 U ta h p l a n G U I D E A e t n a S m a l l G r o u p P P O P l a n s NEW PLAN NAME Utah PPO $750 80/60 Utah PPO $1,000 80/60 Utah PPO $1,000 Value OON Reimbursement Recognized amount* Recognized amount* Network Open Choice PPO N/A Open Choice PPO N/A Open Choice PPO N/A Recognized amount* Member Benefits Network Out-of-Network Network Out-of-Network Network Out-of-Network Member Coinsurance (Applies to most services) Calendar Year Deductible** (In-Network and Out-of-Network accumulate separately) Calendar Year Coinsurance Limit*** (does not include deductible) 20% 20% 20% $750 per member $2,250 per member $1,500 per member $4,500 per member $1,000 per member $2,500 per member $2,000 per member $5,000 per member $1,000 per member (three-member $2,500 per member (three-member Lifetime Maximum Benefit $2,000,000 $2,000,000 $2,000,000 Primary Physician Office Visit Specialist Office Visit $15 copay $25 copay $20 copay $30 copay $25 copay $40 copay $2,000 per member (three-member $5,000 per member (three-member Chiropractic Services Covered under PT/OT/ST Covered under PT/OT/ST Covered under PT/OT/ST Outpatient Lab and X-ray (services included with office visit cost sharing) Outpatient Complex Imaging (CAT, MRI, MRA/MRS and PET Scans) Outpatient Physical, Occupational, Speech and Chiropractic Therapy PT/OT/ST/CT Limits Physical Exams Adults (Age and frequency schedules apply; $300 max benefit per exam) Well-Child Exams (Age and frequency schedules apply) Routine GYN (Frequency schedules apply) $0 $0 $25 copay 30% 50% 30% 50% 30% 50% 20% 20% 20% 30 visits per cal year all therapies combined, Network and Out-of-Network combined $15 copay $15 copay $25 copay $20 copay $20 copay $30 copay 30 visits per cal year all therapies combined, Network and Out-of-Network combined $25 copay $25 copay $40 copay 30 visits per cal year all therapies combined, Network and Out-of-Network combined Inpatient Hospital 20% 20% 20% Outpatient Surgery OP Hospital Department Freestanding Facility Emergency Room (Copay waived if admitted.) Urgent Care Prescription Drugs Retail: per 30-day supply Mail Order: 2.5 times retail copay, 90-day supply available Self-Injectable Drugs (retail and mail order) 20% 20% 20% after $150 copay $50 copay Paid as in-network 20% 20% 20% after $150 copay $75 copay Paid as in-network $200 copay + 20% 20% 20% after $200 copay $75 copay $15/$30/$50 $15/$30/$ % $15/$30/$60 $15/$30/$ % $15/$40/$60 3X Retail for 90 day supply via MOD 20% 20% 20% 20% 20% 20% $200 copay + Paid as in-network $15/$30/$ % * Payment for Non-Preferred facility care is determined based upon Aetna s Allowable Fee Schedule. Payment for other Non-Preferred care is determined based upon the negotiated charge that would apply if such services or supplies were received from a Preferred Provider. For more information, see the How Aetna pays claims for out-of-network benefits brochure. This brochure will be mailed directly to members after they enroll. ** Unless otherwise indicated, the Deductible must be met prior to benefits being payable. Once 2 individual members of a family each satisfy their Deductible amount separately, all family members will be considered as having met their Deductible for the remainder of the calendar year. For the Value plans, once 3 individual members of a family each satisfy their Deductible amount separately, all family members will be considered as having met their Deductible for the remainder of the calendar year. *** All covered expenses accumulate separately toward the preferred and non-preferred Coinsurance Limit. Only those preferred & non-preferred expenses resulting from the application of coinsurance percentage (except any penalty amounts) may be used to satisfy the Coinsurance Limit. Certain member cost sharing elements including deductible, copays, pharmacy, mental health and substance abuse do not apply toward the Coinsurance Limit. Once 2 individual members of a family each satisfy their Coinsurance Limit separately, all family members will be considered as having met their Coinsurance Limit for the remainder of the calendar year. For the Value plans, once 3 individual members of a family each satisfy their Coinsurance Limit separately, all family members will be considered as having met their Coinsurance Limit for the remainder of the calendar year. 8

11 A e t n a S m a l l G r o u p P P O P l a n s NEW PLAN NAME Utah PPO $1,500 80/60 Utah PPO $1,500 Value OON Reimbursement Recognized amount* Network Open Choice PPO N/A Open Choice PPO N/A Recognized amount* Member Benefits Network Out-of-Network Network Out-of-Network Member Coinsurance (Applies to most services) Calendar Year Deductible** (In-Network and Out-of-Network accumulate separately) Calendar Year Coinsurance Limit*** (does not include deductible) 20% 20% $1,500 per member $3,000 per member $3,000 per member $5,000 per member $1,500 per member (three-member $3,000 per member (three-member Lifetime Maximum Benefit $2,000,000 $2,000,000 Primary Physician Office Visit Specialist Office Visit $25 copay $35 copay $30 copay $50 copay $3,000 per member (three-member $5,000 per member (three-member Chiropractic Services Covered under PT/OT/ST Covered under PT/OT/ST Outpatient Lab and X-ray (services included with office visit cost sharing) Outpatient Complex Imaging (CAT, MRI, MRA/MRS and PET Scans) Outpatient Physical, Occupational, Speech and Chiropractic Therapy PT/OT/ST/CT Limits Physical Exams Adults (Age and frequency schedules apply; $300 max benefit per exam) Well-Child Exams (Age and frequency schedules apply) Routine GYN (Frequency schedules apply) $0 $30 copay 30% 50% 30% 50% 20% 20% 30 visits per cal year all therapies combined, Network and Out-of-Network combined $25 copay $25 copay $35 copay $30 copay $30 copay $50 copay 30 visits per cal year all therapies combined, Network and Out-of-Network combined Inpatient Hospital 20% 20% Outpatient Surgery OP Hospital Department Freestanding Facility Emergency Room (Copay waived if admitted.) Urgent Care Prescription Drugs Retail: per 30-day supply Mail Order: 2.5 times retail copay, 90-day supply available Self-Injectable Drugs (retail and mail order) 20% 20% 20% after $200 copay $75 copay Paid as in-network $200 copay + 20% 20% 20% after $200 copay $75 copay $15/$40/$60 $15/$40/$ % $15/$40/$60 3X Retail for 90 day supply via MOD $200 copay + Paid as in-network 20% 20% 20% 20% $15/$30/$ % * Payment for Non-Preferred facility care is determined based upon Aetna s Allowable Fee Schedule. Payment for other Non-Preferred care is determined based upon the negotiated charge that would apply if such services or supplies were received from a Preferred Provider.For more information, see the How Aetna pays claims for out-of-network benefits brochure. This brochure will be mailed directly to members after they enroll. ** Unless otherwise indicated, the Deductible must be met prior to benefits being payable. Once 2 individual members of a family each satisfy their Deductible amount separately, all family members will be considered as having met their Deductible for the remainder of the calendar year. For the Value plans, once 3 individual members of a family each satisfy their Deductible amount separately, all family members will be considered as having met their Deductible for the remainder of the calendar year. *** All covered expenses accumulate separately toward the preferred and non-preferred Coinsurance Limit. Only those preferred & non-preferred expenses resulting from the application of coinsurance percentage (except any penalty amounts) may be used to satisfy the Coinsurance Limit. Certain member cost sharing elements including deductible, copays, pharmacy, mental health and substance abuse do not apply toward the Coinsurance Limit. Once 2 individual members of a family each satisfy their Coinsurance Limit separately, all family members will be considered as having met their Coinsurance Limit for the remainder of the calendar year. For the Value plans, once 3 individual members of a family each satisfy their Coinsurance Limit separately, all family members will be considered as having met their Coinsurance Limit for the remainder of the calendar year. M E D I C A L / P H A R M A C Y D E N TA L L I F E / D I S A B I L I T Y U N D E R W R I T I N G 9

12 U ta h p l a n G U I D E A e t n a S m a l l G r o u p P P O P l a n s NEW PLAN NAME Utah PPO $2,000 80/60 Utah PPO $3,000 80/60 Utah PPO $10, % OON Reimbursement Recognized amount* Recognized amount* Network Open Choice PPO N/A Open Choice PPO N/A Open Choice PPO N/A Recognized amount* Member Benefits Network Out-of-Network Network Out-of-Network Network Out-of-Network Member Coinsurance (Applies to most services) Calendar Year Deductible** (In-Network and Out-of-Network accumulate separately) Calendar Year Coinsurance Limit*** (does not include deductible) 20% 20% 0% 25% $2,000 per member $3,500 per member $4,000 per member $7,000 per member $3,000 per member $4,000 per member $6,000 per member maximum $8,000 per member $10,000 per member $10,000 family + $10,000 per member $10,000 family ++ Lifetime Maximum Benefit $2,000,000 $2,000,000 $2,000,000 Primary Physician Office Visit Specialist Office Visit $30 copay $40 copay $30 copay $50 copay $15 copay $10,000 per member $10,000 family + $20,000 per member $20,000 family ++ 25% 0% 25% Chiropractic Services Covered under PT/OT/ST Covered under PT/OT/ST Covered under PT/OT/ST Outpatient Lab and X-ray (services included with office visit cost sharing) Outpatient Complex Imaging (CAT, MRI, MRA/MRS and PET Scans) Outpatient Physical, Occupational, Speech and Chiropractic Therapy PT/OT/ST/CT Limits Physical Exams Adults (Age and frequency schedules apply; $300 max benefit per exam) Well-Child Exams (Age and frequency schedules apply) Routine GYN (Frequency schedules apply) $0 $0 0% 25% 30% 50% 30% 50% 0% 25% 20% 20% 0% 25% 30 visits per cal year all therapies combined, Network and Out-of-Network combined $30 copay $30 copay $40 copay $30 copay $30 copay $50 copay 30 visits per cal year all therapies combined, Network and Out-of-Network combined $15 copay $15 copay $15 copay 30 visits per cal year all therapies combined, Network and Out-of-Network combined Inpatient Hospital 20% 20% 0% 25% Outpatient Surgery OP Hospital Department Freestanding Facility Emergency Room (Copay waived if admitted.) Urgent Care Prescription Drugs Retail: per 30-day supply Mail Order: 2.5 times retail copay, 90-day supply available Self-Injectable Drugs (retail and mail order) 20% 20% 20% after $200 copay $75 copay Paid as in-network 20% 20% 20% after $200 copay $75 copay 0% 0% 25% 25% 25% 25% 25% Paid as in-network 0% Paid as in-network 0% 25% $20/$40/$60 $20/$40/$ % $20/$40/$60 $20/$40/$ % $20/$40/$60 $20/$40/$ % 20% 20% 20% 20% 20% 20% 10 * Payment for Non-Preferred facility care is determined based upon Aetna s Allowable Fee Schedule. Payment for other Non-Preferred care is determined based upon the negotiated charge that would apply if such services or supplies were received from a Preferred Provider. For more information, see the How Aetna pays claims for out-of-network benefits brochure. This brochure will be mailed directly to members after they enroll. ** Unless otherwise indicated, the Deductible must be met prior to benefits being payable. Once 2 individual members of a family each satisfy their Deductible amount separately, all family members will be considered as having met their Deductible for the remainder of the calendar year. *** All covered expenses accumulate separately toward the preferred and non-preferred Coinsurance Limit. Only those preferred & non-preferred expenses resulting from the application of coinsurance percentage (except any penalty amounts) may be used to satisfy the Coinsurance Limit. Certain member cost sharing elements including deductible, copays, pharmacy, mental health and substance abuse do not apply toward the Coinsurance Limit. Once 2 individual members of a family each satisfy their Coinsurance Limit separately, all family members will be considered as having met their Coinsurance Limit for the remainder of the calendar year. + Unless otherwise indicated, the Deductible must be met prior to benefits being payable. Expenses accumulate separately toward the preferred and non-preferred deductibles. Once the Family Deductible is met, all family members will be considered as having met their Deductible for the remainder of the calendar year. No one family member is required to contribute more than the Individual Deductible amount toward the Family Deductible. ++ All covered expenses accumulate separately toward the preferred and non-preferred coinsurance Limit. Only those preferred & non-preferred expenses resulting from the application of coinsurance percentage (except any penalty amounts) may be used to satisfy the coinsurance Limit. Certain member cost sharing elements including copays, pharmacy, mental health and substance abuse do not apply toward the coinsurance Limit. Once the Family Coinsurance Limit is met, all family members will be considered as having met their Coinsurance Limit for the remainder of the calendar year.

13 A e t n a S m a l l G r o u p P P O P l a n s NEW PLAN NAME OON Reimbursement Utah $2, % HSA compatible Recognized amount* Utah $2,500 80% HSA compatible Recognized amount* Utah $3,500 80% HSA compatible Network Open Choice PPO N/A Open Choice PPO N/A Open Choice PPO N/A Recognized amount* Member Benefits In-Network Out-of-Network Network Out-of-Network Network Out-of-Network Member Coinsurance (Applies to most services) Calendar Year Deductible** (In-Network and Out-of-Network accumulate separately) Calendar Year Coinsurance Limit*** (Includes deductible) 0% 25% 20% 20% $2,500 individual $5,000 family $2,500 individual $5,000 family $5,000 individual $10,000 family $10,000 individual $20,000 family $2,500 per member $5,000 family $5,800 per member $11,600 family $5,000 per member $10,000 family $12,000 per member $24,000 family $3,500 per member $7,000 family $5,800 per member $11,600 family Lifetime Maximum Benefit $2,000,000 $2,000,000 $2,000,000 Primary Physician Office Visit 0% 25% 20% 20% Specialist Office Visit 0% 25% 20% 20% $6,000 per member $12,000 family $12,000 per member $24,000 family Chiropractic Services Covered under PT/OT/ST Covered under PT/OT/ST Covered under PT/OT/ST Outpatient Lab and X-ray (services included with office visit cost sharing) Outpatient Complex Imaging (CAT, MRI, MRA/MRS and PET Scans) Outpatient Physical, Occupational, Speech and Chiropractic Therapy PT/OT/ST/CT Limits Physical Exams Adults (Age and frequency schedules apply; $300 max benefit per exam) Well-Child Exams (Age and frequency schedules apply) Routine GYN (Frequency schedules apply) 0% 25% 20% 20% 0% 25% 30% 50% 30% 50% 0% 25% 20% 20% 30 visits per cal year all therapies combined, Network and Out-of-Network combined $0 copay $0 copay $0 copay 25% $0 copay 25% $0 copay 25% $0 copay 30 visits per cal year all therapies combined, Network and Out-of-Network combined 25% $0 copay 25% $0 copay 25% $0 copay 30 visits per cal year all therapies combined, Network and Out-of-Network combined Inpatient Hospital 0% 25% 20% 20% Outpatient Surgery OP Hospital Department Freestanding Facility Emergency Room (Copay waived if admitted.) 0% 0% 25% 25% 20% 20% 0% Paid as in-network 20% Paid as in-network 20% Paid as in-network Urgent Care 0% 25% 20% 20% Prescription Drugs Retail: per 30-day supply Mail Order: 2.5 times retail copay, 90-day supply available Self-Injectable Drugs (retail and mail order) Prescription Drug Deductible 100% (paid by plan) after medical plan deductible 100% (paid by plan) after medical plan deductible Integrated with Medical 75% (paid by plan) after medical plan deductible 75% (paid by plan) after medical plan deductible Integrated with Medical $15/$30/$50 after medical plan deductible 20% after medical plan deductible Integrated with Medical $15/$30/$ % after medical plan deductible 20% after medical plan deductible Integrated with Medical 20% 20% $15/$30/$50 after medical plan deductible 20% after medical plan deductible Integrated with Medical 25% 25% 25% $15/$30/$ % after medical plan deductible 20% after medical plan deductible Integrated with Medical * Payment for Non-Preferred facility care is determined based upon Aetna s Allowable Fee Schedule. Payment for other Non-Preferred care is determined based upon the negotiated charge that would apply if such services or supplies were received from a Preferred Provider. For more information, see the How Aetna pays claims for out-of-network benefits brochure. This brochure will be mailed directly to members after they enroll. ** Unless otherwise indicated, the Deductible must be met prior to benefits being payable. Expenses accumulate separately toward the preferred and non-preferred deductibles. Once the Family Deductible is met, all family members will be considered as having met their Deductible for the remainder of the calendar year. No one family member is required to contribute more than the Individual Deductible amount toward the Family Deductible. *** The Coinsurance Limit for HSA compatible plans includes preferred & non-preferred out-of-pocket expenses resulting from the application of coinsurance percentage, deductibles, and copays (except any penalty amounts). All covered expenses accumulate separately toward the preferred and non-preferred Coinsurance Limit. Once the Family Coinsurance Limit is met, all family members will be considered as having met their Coinsurance Limit for the remainder of the calendar year. No one family member is required to contribute more than the Individual Deductible amount toward the Family Deductible. M E D I C A L / P H A R M A C Y D E N TA L L I F E / D I S A B I L I T Y U N D E R W R I T I N G 11

14 U ta h p l a n G U I D E A e t n a S m a l l G r o u p P P O P l a n s NEW PLAN NAME Utah $2,500 Coinsurance Utah Basic PPO $1,500 70/55 Utah Limited Benefit 50/50 OON Reimbursement Recognized amount* Recognized amount* Network Open Choice PPO N/A Open Choice PPO N/A Open Choice PPO N/A Recognized amount* Member Benefits Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network Member Coinsurance (Applies to most services) Calendar Year Deductible** (In-Network and Out-of-Network accumulate separately) Calendar Year Coinsurance Limit*** (does not include deductible) 20% 30% 45% 50% 50% $2,500 per member $5,000 per member $5,000 per member $10,000 per member (twomember $1,500 per member $4,500 per member $3,000 per member $9,000 per member $1,500 per member $4,500 per member $3,000 per member $9,000 per member Lifetime Maximum Benefit $2,000,000 $2,000,000 $2,000,000 Lifetime maximum $25,000 annual benefit maximum Primary Physician Office Visit 20% $35 copay Specialist Office Visit 20% $35 copay 45% 50% 50% 45% 50% 50% Chiropractic Services Covered under PT/OT/ST Covered under PT/OT/ST Covered under PT/OT/ST Outpatient Lab and X-ray (services included with office visit cost sharing) Outpatient Complex Imaging (CAT, MRI, MRA/MRS and PET Scans) Outpatient Physical, Occupational, Speech and Chiropractic Therapy PT/OT/ST/CT Limits Physical Exams Adults (Age and frequency schedules apply; $300 max benefit per exam) Well-Child Exams (Age and frequency schedules apply) Routine GYN (Frequency schedules apply) 20% 30% after deductible; $500 max benefit for lab, X-ray and complex imaging combined, Network and Out-of-Network combined 30% 50% See Outpatient Lab and X-ray 45% after deductible; $500 max benefit for lab, X-ray and complex imaging combined, Network and Out-of-Network combined See Outpatient Lab and X-ray 50% after deductible; $500 max benefit for lab, X-ray and complex imaging combined, Network and Out-of-Network combined See Outpatient Lab and X-ray 20% 30% 45% 50% 50% 30 visits per cal year all therapies combined, Network and Out-of-Network combined $0 copay $0 copay $0 copay 25% $35 copay 25% $35 copay 25% $35 copay 30 visits per cal year all therapies combined, Network and Out-of-Network combined 45% $30 copay 45% $30 copay 45% $30 copay 50% after deductible; $500 max benefit for lab, X-ray and complex imaging combined, Network and Out-of-Network combined See Outpatient Lab and X-ray 30 visits per cal year all therapies combined, Network and Out-of-Network combined Inpatient Hospital 20% 30% 45% 50% 50% Outpatient Surgery OP Hospital Department Freestanding Facility Emergency Room (Copay waived if admitted.) 20% 20% $200 copay + 30% 30% $200 copay + 45% 45% $200 copay+ 50% 50% 50% 50% 50% $200 copay + 50% 50% 20% Paid as in-network 30% Paid as in-network 50% Paid as in-network Urgent Care 20% 30% 45% 50% 50% Prescription Drugs Retail: per 30-day supply Mail Order: 2.5 times retail copay, 90-day supply available Self-Injectable Drugs (retail and mail order) $15/$40/$60 $15/$40/$ % $10 Generics. Member pays 100% for Brand meds 3X Retail for 90 day supply via MOD $ % for Generics; Member pays 100% for Brand meds $10 Generics. Member pays 100% for Brand meds 3X Retail for 90 day supply via MOD 20% 20% 20% 20% 20% 20% $ % for Generics; Member pays 100% for Brand meds * Payment for Non-Preferred facility care is determined based upon Aetna s Allowable Fee Schedule. Payment for other Non-Preferred care is determined based upon the negotiated charge that would apply if such services or supplies were received from a Preferred Provider. For more information, see the How Aetna pays claims for out-of-network benefits brochure. This brochure will be mailed directly to members after they enroll. ** Unless otherwise indicated, the Deductible must be met prior to benefits being payable. Once 2 individual members of a family each satisfy their Deductible amount separately, all family members will be considered as having met their Deductible for the remainder of the calendar year. *** All covered expenses accumulate separately toward the preferred and non-preferred Coinsurance Limit. Only those preferred & non-preferred expenses resulting from the application of coinsurance percentage (except any penalty amounts) may be used to satisfy the Coinsurance Limit. Certain member cost sharing elements including deductible, copays, pharmacy, mental health and substance abuse do not apply toward the Coinsurance Limit. Once 2 individual members of a family each satisfy their Coinsurance Limit separately, all family members will be considered as having met their Coinsurance Limit for the remainder of the calendar year. 12

15 A e t n a S m a l l G r o u p I n d e m n i t y P l a n NEW PLAN NAME Aetna Indemnity OON Reimbursement Network N/A Member Benefits N/A Member Coinsurance 30% (Applies to most services) Calendar Year Deductible* $1,000 per member (In-Network and Out-of-Network accumulate separately) Calendar Year Coinsurance Limit** $3,000 per member (does not include deductible) Lifetime Maximum Benefit $2,000,000 Primary Physician Office Visit 30% Specialist Office Visit 30% Chiropractic Services Covered Under PT/OT/ST Outpatient Lab and X-ray 30% (services included with office visit cost sharing) Outpatient Complex Imaging (CAT, MRI, MRA/MRS and PET Scans) Outpatient Physical, Occupational, 30% Speech and Chiropractic Therapy PT/OT/ST/CT Limits 30 visits per cal year all therapies combined, Network and Out-of-Network combined Physical Exams Adults 30% (Age and frequency schedules apply; $300 max benefit per exam) Well-Child Exams 30% (Age and frequency schedules apply) Routine GYN 30% (Frequency schedules apply) Inpatient Hospital 30% Outpatient Surgery OP Hospital Department Freestanding Facility Emergency Room (Copay waived if admitted.) 30% 30% 30% Urgent Care 30% Prescription Drugs $20/$40/$60 Retail: per 30-day supply Mail Order: 2.5 times retail copay, 90-day supply available Self-Injectable Drugs 20% (retail and mail order) Prescription Drug Deductible $200 Individual $400 Family * Unless otherwise indicated, the Deductible must be met prior to benefits being payable. Once 2 individual members of a family each satisfy their Deductible amount separately, all family members will be considered as having met their Deductible for the remainder of the calendar year. ** All covered expenses accumulate separately toward the preferred and non-preferred Coinsurance Limit. Only those preferred & non-preferred expenses resulting from the application of coinsurance percentage (except any penalty amounts) may be used to satisfy the Coinsurance Limit. Certain member cost sharing elements including deductible, copays, pharmacy, mental health and substance abuse do not apply toward the Coinsurance Limit. Once 2 individual members of a family each satisfy their Coinsurance Limit separately, all family members will be considered as having met their Coinsurance Limit for the remainder of the calendar year. M E D I C A L / P H A R M A C Y D E N TA L L I F E / D I S A B I L I T Y U N D E R W R I T I N G 13

16 U ta h p l a n G U I D E Aetna Avenue d e n ta l O v e r v i e w A e t n a D e n ta l p l a n s Small business decision makers can choose from a variety of plan design options that help you offer a dental insurance plan that s just right for your employees. The Mouth Matters SM Research shows that more than 90 percent of all medical illnesses are detectable in the mouth and that 75 percent of people over the age of 35 have periodontal (gum) disease. 1 Untreated oral diseases can have a big impact on the quality of life. This means that a dentist may be the first health care provider to diagnose a health problem! Aetna Dental/Medical Integration SM program, available at no additional charge to plan sponsors that have both medical and dental coverages with Aetna, focuses on those who are pregnant or have diabetes, coronary artery disease (heart disease) or cerebrovascular disease (stroke) and have not had a recent dental visit. We proactively educate those at-risk members about the impact oral health care can have on their condition. Our member outreach has been proven to successfully motivate those at-risk members who do not normally seek dental care to visit the dentist. Once at the dentist, these at-risk members will receive enhanced dental benefits including an extra cleaning and full coverage for certain periodontal services. Preferred Provider Organization (PPO) plan Members can choose a dentist who participates in the network or choose a licensed dentist who does not. Participating dentists have agreed to offer our members services at a negotiated rate and will not balance-bill members. PPO Max plan While the PPO Max dental insurance plan uses the PPO network, members who use out-of-network dentists will be covered based on the Aetna PPO fee schedule. For more information, see the How Aetna pays claims for out-of-network benefits brochure. This brochure will be mailed directly to members after they enroll. The member will share in more of the costs and may be balance-billed. This plan offers members a quality dental insurance plan with a significantly lower premium that encourages in-network usage. Voluntary Dental option The Voluntary Dental option provides a solution to meet the individual needs of members in the face of rising health care costs. Administration is easy, and members benefit from low group rates and the convenience of payroll deductions. Employers choose how the plan is funded. It can be entirely member-paid or employers can contribute up to 50 percent. 1 The professional entity, Academy of General Dentistry, DMI may not be available in all states. 14

17 S m a l l G r o u p D e n ta l P l a n s Available With an Aetna Medical Plan to Groups with 2 50 Eligible Employees Available Without Medical Plan (Dental Standalone) to Groups with Eligible Employees Option 1 PPO Max 1000 PPO Max Plan 100/80/50 Preferred Plan 100/80/50 Option 2 PPO Active 1000 Non-Preferred Plan 80/60/40 Office Visit Copay N/A N/A N/A N/A Annual Deductible per Member (Does not apply to Diagnostic & Preventive services) PPO Plan 100/80/50 Option 3 PPO 1000 $50; 3X Family Maximum $50; 3X Family Maximum $50; 3X Family Maximum $50; 3X Family Maximum Annual Maximum Benefit $1,000 $1,000 $1,000 $1,000 Diagnostic Services Oral Exams Periodic oral exam 100% 100% 80% 100% Comprehensive oral exam 100% 100% 80% 100% Problem-focused oral exam 100% 100% 80% 100% X-rays Bitewing - single film 100% 100% 80% 100% Complete series 100% 100% 80% 100% Preventive Services Adult Cleaning 100% 100% 80% 100% Child Cleaning 100% 100% 80% 100% Sealants - per tooth 100% 100% 80% 100% Fluoride application - with cleaning 100% 100% 80% 100% Space maintainers 100% 100% 80% 100% Basic Services Amalgam filling - 2 surfaces 80% 80% 60% 80% Resin filling - 2 surfaces, anterior 80% 80% 60% 80% Oral Surgery Extraction - exposed root or erupted tooth 80% 80% 60% 80% Extraction of impacted tooth - soft tissue 80% 80% 60% 80% *Major Services Complete upper denture 50% 50% 50% Partial upper denture (resin base) 50% 50% 50% Crown - Porcelain with noble metal 50% 50% 50% Pontic - Porcelain with noble metal 50% 50% 50% Inlay - Metallic (3 or more surfaces) 50% 50% 50% Oral Surgery Removal of impacted tooth - partially bony 50% 50% 50% Endodontic Services Bicuspid root canal therapy 50% 50% 80% Molar root canal therapy 50% 50% 50% Periodontic Services Scaling & root planing - per quadrant 50% 50% 80% Osseous surgery - per quadrant 50% 50% 50% *Orthodontic Services Not covered Not covered Not covered 50% Orthodontic Lifetime Maximum Does not apply Does not apply Does not apply $1,000 *Coverage Waiting Period: Must be an enrolled member of the Plan for 12 months before becoming eligible for coverage of any Major Service including Orthodontic Services. Access to negotiated discounts; Members are eligible to receive non-covered services at the PPO negotiated rate when visiting a participating PPO dentist at any time, including during the Coverage Waiting Period. Most Oral Surgery, Endodontic and Periodontic services are covered as Basic Services in Options 4, 5, & 6. Plan Options 1 & 4; PPO Max Non-Preferred (Out-of-Network) Coverage is limited to a maximum of the Plan s payment, which is based on the contracted maximum fee for participating providers in the particular geographic area. Orthodontic coverage is available only to groups with 10 or more eligibles and for dependent children only. Above list of covered services is representative. Full list with limitations as determined by Aetna appears on the plan booklet/certificate. For a summary list of Limitations and Exclusions, refer to page 44. M E D I C A L / P H A R M A C Y D E N TA L L I F E / D I S A B I L I T Y U N D E R W R I T I N G 15